Who gets how much of the public health budget?

In February, I blogged about the Department of Health’s attempt to assess how much the NHS has historically spent on public health and what that would mean if allocated to the key organisations in the new system. In particular, the Department needs to know this in order to transfer funds to local authorities so they can fulfil their new public health commitments from 2013-14. How much local authorities get will be decided centrally for the first time, in contrast to the current system where primary care trusts take their own decisions.

The Department asked the Advisory Council of Resource Allocation (ACRA) to help it make that decision. Its recommendations have now been released in Healthy Lives, Healthy People: Update on public health funding. The new document does take some steps forward. Importantly, the allocation of funding will be based on need at small neighbourhood level which will ensure that it is more precise. For example, wealthier local authorities with small but concentrated pockets of need should receive the appropriate funding to deal with it.

Back in February, I argued that the trickiest decision for the Department will be whether to stick with the historical pattern of spending, or if that seems really out of line with need, to allocate it on some other basis. ACRA has now recommended, and the Department has accepted, that the measure that should be used – at least initially – is the under 75 standardised mortality ratio.

Figure one therefore shows the Department’s estimates of how much local authorities would get under the current system against ACRA’s recommendations on how that total amount should be allocated.

Figure one: Allocation of public health resources to local authorities: Flows to on the basis of new system responsibilities in 2010-11 vs ACRA's recommendations

This graph shows a real divergence. Only 56 per cent of local authorities are actually within 25 per cent either way of where ACRA’s formula suggests they should be based on 2010-11 total spend. Clearly, individual primary care trust (PCT) decisions taken across the country, when seen as a whole, have been poor at matching the need for public health interventions.

Figure two plots the extent of under- or over-funding against the deprivation levels of local authorities. It sheds light on whether current spending in the poorer, more deprived communities is more or less out of synch than the better off ones. The vertical axis shows how far each local authority is adrift from ACRA’s recommendation, the horizontal axis shows the index of multiple deprivation, with smaller numbers meaning lower deprivation. In short, it shows that higher levels of under-funding tend to be seen in less deprived local authorities and vice-versa, although the relationship is not strong.

Figure two: Public health under- or over-funding by local authority according to ACRA's recommendations vs index of  multiple deprivation

Public health under- or over-funding by local authority according to ACRA's recommendations vs index of multiple deprivation. From the perspective of improving population health, these graphs make a compelling case to move quickly to ACRA’s preferred allocation. Public health funds are not where they should be. What then does the Department have to say about this? On page 9 it states, '...the current restrictions on growth in public health spending will mean that, initially, progress towards the preferred distribution is likely to be slow.’ This is bad news for the public health of England. Faster progress, getting under-funded areas closer to the preferred allocation, ideally funded through growth in the public health budget, would be a strong demonstration of the government’s commitment to reduce health inequalities.